Beneficence: this considers the balancing of benefits of treatment against the risks and costs; the healthcare professional should act in a way that benefits the patient

Non maleficence: avoiding the causation of harm; the healthcare professional should not harm the patient. All treatment involves some harm, even if minimal, but the harm should not be disproportionate to the benefits of treatment.

Justice: distributing benefits, risks and costs fairly; the notion that patients in similar positions should be treated in a similar manner.

To get some feel for how the Four Principles could be used by a clinical ethics committee consider the following hypothetical case study.

Mrs Y is 56 years old and has a learning disability. She is admitted to hospital with an ovarian cyst. The cyst is blocking her ureter and if left untreated will result in renal failure. Mrs Y would need an operation to remove the cyst. Mrs Y has indicated quite clearly that she does not want a needle inserted for the anaesthetic for the operation to remove the cyst- she is uncomfortable in a hospital setting and is frightened of needles.

The clinician is concerned that if the cyst is not removed Mrs Y will develop renal failure and require dialysis which would involve the regular use of needles and be very difficult to carry out given her fear of needles and discomfort with hospitals. The anaesthetist is concerned that if Mrs Y does not comply with the procedure then she would need to be physically restrained. Mrs Y’s niece visits her in the care home every other month. The niece is adamant that her aunt should receive treatment.

Should the surgeon perform the operation despite Mrs Y’s objections?

Consideration of the ethical issues using the Four Principles framework

Respect for autonomy:

The principle of respect for autonomy entails taking into account and giving consideration to the patient’s views on his/ her treatment. Autonomy is not an all or nothing concept. Mrs Y may not be fully autonomous (and not legally competent to refuse treatment) but this does not mean that ethically her views should not be considered and respected as far as possible. She has expressed her wishes clearly; she does not want a needle inserted for the anaesthetic. An autonomous decision does not have to be the ‘correct’ decision from an objective viewpoint otherwise individual needs and values would not be respected. However an autonomous decision is one that is informed – has Mrs Y been given enough information, in a manner that she can comprehend?

Beneficence:

The healthcare professional should act to benefit his/her patient. This principle may clash with the principle of respect for autonomy when the patient makes a decision that the healthcare professional does not think will benefit the patient – is not in her best interests. Here we should consider both the long term and short -term effects of overriding Mrs Y’s views. In the short - term Mrs Y will be frightened to have a needle inserted in her arm and to be in hospital – this may lead her to distrust healthcare professionals in the future and to be reluctant to seek medical help. In the long term there will be a benefit to Mrs Y in having her autonomy overridden on this occasion. Without treatment she will suffer serious and long-term health problems that would require greater medical intervention (ongoing dialysis) than the treatment required now (operation).

The benefits of acting beneficently would need to be weighed against the dis-benefits of failing to respect Mrs Y’s autonomy. (From a legal point of view the wishes of a competent patient cannot be overridden in his best interests).

Non maleficence:

Do no harm to the patient. Here, Mrs Y would be harmed by forcibly restraining her in order to insert the needle for anaesthesia. On the other hand if she is not treated now she will require ongoing dialysis a number of times per week. If she does not comply with dialysis it would be impractical to administer and may require restraint. Which course of action would result in the greatest harm? This assessment relies on assumptions: how successful is the operation likely to be; how likely will Mrs Y comply with dialysis?

Justice:

It would be relevant to consider cost effectiveness of the treatment options for Mrs Y, and the impact the decision about her treatment has on the availability of treatment for others (awaiting dialysis).